Please send completed application to:
NYU School of Medicine
Center for Brain Health
Dept. of Psychiatry, MHL 400
550 First Avenue
New York, NY 10016
____________________________________________________________________________
(All information supplied in this questionnaire is strictly confidential)
DATE: _____/_____/_____
NAME: ___________________________________________________________________________
First
Initial
Last
ADDRESS: _________________________________________________________________________
___________________________________________________________________________________
HOME: (
) ____________- _________________ WORK: (
) ____________- ________________
E-MAIL: ____________________________________________________________________________
SS#: ____________________________
REFERRED BY: ________________________________
APPLICANT INFORMATION:
AGE: _______
HEIGHT: _____________ WEIGHT: __________
SEX: __________
DATE OF BIRTH: ______/______/______
BIRTHPLACE: ____________________________
PRIMARY LANGUAGE SPOKEN: ________________________________________
SECOND LANGUAGE(S): _______________________________________________
MARITAL STATUS (Check one):
□ Single (never married)
□ Widowed □ Divorced
□ Married
□ Separated
If married, name of spouse: ____________________________________________________
RACE:
□ African American □ Caucasian
□ Asian
□ Hispanic
□ Other _________________________
RELIGION: _______________________________
CURRENTLY EMPLOYED:
□
Yes
□
No
□ Retired
If retired, # of years since retiring: _____________
OCCUPATION (or type of work): _______________________________________________________
YEARS OF EDUCATION: _________ HIGHEST DEGREE OBTAINED: _________________
PRIMARY CONTACT PERSON:
NAME: _____________________________________________________________________________
RELATIONSHIP TO APPLICANT: ______________________________________________________
ADDRESS: _________________________________________________________________________
___________________________________________________________________________________
HOME: (
) ____________- _________________ WORK: (
) ____________- ________________
E-MAIL: ____________________________________________________________________________
RELATIVE OR FRIEND:(in addition to PRIMARY CONTACT PERSON above)
NAME: _____________________________________________________________________________
RELATIONSHIP TO APPLICANT: ______________________________________________________
ADDRESS: _________________________________________________________________________
___________________________________________________________________________________
HOME: (
) ____________- _________________ WORK: (
) ____________- ________________
E-MAIL: ____________________________________________________________________________
PRINCIPAL FAMILY PHYSICIAN
NAME: __________________________________________________________________
OFFICE PHONE: (
) _________ - _____________________
ADDRESS: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
CHECK ONLY ONE RELEVANT COLUMN FOR EACH SYMPTOM
(from not at all present to severe):
SYMPTOM
NOT AT ALL
MILD
MODERATE SEVERE
ANXIETY
______
______
______
______
TENSION
______
______
______
______
AGITATION
______
______
______
______
DEPRESSION
______
______
______
______
CONFUSION
______
______
______
______
DISORIENTATION
______
______
______
______
POOR MEMORY
______
______
______
______
POOR CONCENTRATION
______
______
______
______
REDUCED ACTIVITIES
______
______
______
______
POOR MOTIVATION
______
______
______
______
FATIGUE
______
______
______
______
INSOMNIA
______
______
______
______
DISTURBED SLEEP
______
______
______
______
POOR APPETITE
______
______
______
______
SEXUAL PROBLEMS
______
______
______
______
INCONTINENCE
______
______
______
______
PANIC REACTIONS
______
______
______
______
IRRATIONAL THOUGHTS
______
______
______
______
DELUSIONS
______
______
______
______
HALLUCINATIONS
______
______
______
______
OTHER(S):_____________
______
______
______
______
MEDICAL HISTORY
APPLICANT’S MEDICAL HISTORY – OPERATIONS AND OTHER HOSPITALIZATIONS:
DATE
TYPE OF OPERATION
TREATMENT
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PLEASE LIST ALL CURRENT MEDICTIONS WITH THEIR TRADE NAMES:
NAME OF MEDICATION
DOSAGE/FREQUENCY
REASON
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
MEDICAL PROBLEMS:
_____ HEART ATTACK
_____ SPLEEN DISEASE
_____ ASTHMA
_____ ANGINA
_____ LIVER DISEASE
_____ DIABETES
_____ PACEMAKER
_____ GASTRIC DISEASE
_____ THYROID
_____ ARRYTHMIA
_____ BOWEL DISEASE
_____ BLINDNESS
_____ HIGH BLOOD PRESSURE
_____ LUNG DISEASE
_____ DEAFNESS
_____ LOW BLOOD PRESSURE
_____ BRONCHIAL DISEASE
_____ VENEREAL DISEASE
_____ KIDNEY DISEASE
_____ ALLERGIES
_____ PAGET’s DISEASE
OTHER PROBLEMS (PLEASE SPECIFY):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PLEASE GIVE DETAILS OF CHECKED ITEMS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
NEUROLOGICAL PROBLEMS:
_____ HEAD INJURY WITH
UNCONSCIOUSNESS
_____ BRAIN SURGERY
_____ STROKE
_____ HEAD INJURY WITHOUT
UNCONSCIOUSNESS
_____ MIGRAINE
_____ SPEECH DISORDER
_____ MENINGITIS
_____ DIZZY SPELLS
_____ FLACCID OR SPASTIC
_____ ENCEPHALITIS
_____ EPILEPSY/SEIZURES
_____ POLIOMYELITIS
_____ APPLICANT WAS AN
AMATEUR OR
_____ LOU GEHRIG’s DISEASE
PROFESSIONAL BOXER
_____ MULTIPLE SCLEROSIS
_____ PARKINSON’S DISEASE
OTHER NEUROLOGICAL PROBLEMS (PLEASE SPECIFY):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PLEASE GIVE DETAILS OF CHECKED ITEMS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PSYCHIATRIC PROBLEMS:
APPLICANT’S HISTORY OF PSYCHIATRIC PROBLEMS:
_____ PSYCHIATRIC HOSPITALIZATIONS ______ DEPRESSION
_____
PSYCIATRIC TREATMENT
_____ SCHIZOPHRENIA
_____BIPOLAR DISORDER
______ ALCOHOLISM
______ DRUG ABUSE
PLEASE SPECIFY:______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
APPLICANT’S FAMILY HISTORY OF PSYCHIATRIC PROBLEMS:
_____ PSYCHIATRIC HOSPITALIZATIONS ______ DEPRESSION
_____
PSYCHIATRIC TREATMENT
_____ SCHIZOPHRENIA
_____BIPOLAR DISORDER
______ ALCOHOLISM
______ DRUG ABUSE
PLEASE SPECIFY:______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
SUBSTANCE USE
HAS THERE EVER BEEN A PERIOD IN YOUR LIFE WHEN YOU HAD THREE OR MORE DRINKS
PER DAY FOR THREE OR MORE DAYS IN A ROW?
___ YES ___ NO
IF YES, HOW LONG AGO?________ WHEN WAS THE LAST TIME? _____
HAVE YOU USED DRUGS LIKE MARIJUANA, COCAINE or HALLUCINGENS?
TYPE? ______________________________________________________________________________
HOW OFTEN? ________________________________________________________________________
WHEN DID YOU LAST USE? ___________________________________________________________
DO YOU TAKE VALIUM, SLEEPING PILLS, TRANQUILIZERS OR PAIN KILLERS?
TYPE? _______________________________________________________________________________
HOW OFTEN? ________________________________________________________________________
WHEN DID YOU LAST USE? ___________________________________________________________
WHY DID YOU CHOOSE TO PARTICIPATE IN THIS RESEARCH STUDY?______________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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